The role of retroperitoneal lymphadenectomy in localized paratesticular rhabdomyosarcoma

Adult Para Testicular Spindle Cell Rhabdomyosarcoma: A Case Report From Pakistan

Para testicular or intra-scrotal Rhabdomyosarcomas (RMS) are rare. The spindle cell variant of rhabdomyosarcoma is the least common variant among embryonal subtypes. They are mostly seen in childhood but rarely reported in adults. We present a case of a 56-year-old man who presented with a three-year history of painless left inguinoscrotal swelling, which he initially ignored and misinterpreted as an Inguinal hernia but later sought medical help upon a progressive increase in the size of the swelling. Clinically and radiologically, there was sparing of the left testis and spermatic cord with normal testicular tumor markers and no evidence of lymphadenopathy or metastasis. Surgical exploration was performed with complete excision of the mass, followed by histopathology and immunocytochemistry, confirming the diagnosis of spindle cell rhabdomyosarcoma. Prompt recognition, early diagnosis, and appropriate surgical treatment are the hallmarks of management. Regular and strict follow-up is needed due to the rarity of diagnosis.

Imaging in paratesticular lesions

A 23-year-old male presented with complaints of gradually increasing swelling of the left hemiscrotum. Preliminary ultrasound scan revealed a heterogeneous, predominantly solid lesion showing raised internal vascularity with few cystic areas in the paratesticular region, towards the midline with both testes seen separately from the lesion. To rule out presence of locoregional or distant metastases, a CT scan was done which revealed a well-defined, intrascotal, extratesticular, heterogeneous, moderately enhancing mass lesion with cystic areas in the scrotal sac with no significant lymphadenopathy or obvious distant metastasis. Subsequent MRI done for surgical planning revealed a heterogeneous signal intensity lesion with cystic areas and areas of haemorrhage with focal loss of fat planes with the left corpora cavernosa at the root of the penis. The patient underwent an inguinoscrotal exploration with excision of the left paratesticular mass. Final histopathology suggested an undifferentiated high grade pleomorphic sarcoma. Paratesticular tumours while rare are an important cause of scrotal swelling. Exact histological identification of tumour subtype is not possible based on imaging but preoperative multi-modality imaging has an important role in identifying tissue of origin, differentiating benign from malignant lesions, surgical planning and assessing the need for adjuvant CT/RT.

Rare benign and malignant testicular lesions: histopathology and management

PURPOSE OF REVIEW

The presence of vascular solid tumors within the testicle is considered to be malignant until proven otherwise. However, it is prudent for clinicians to be aware of rare benign and malignant intratesticular lesions as management can differ from the established treatment algorithms for germ-cell tumors.

RECENT FINDINGS

Utilizing certain histopathologic findings can assist with the diagnosis of rare testis tumors. Often times the tumor subtypes are an important consideration in the grading and classification of the disease, which drives management. The multidisciplinary management of rare malignant testis tumors at an experienced center seems to provide optimal patient outcomes. Regardless of the primary treatment, prolonged follow-up for sex cord stromal tumors and other rare testis malignancies is advocated due to the delayed metastatic potential.

SUMMARY

The clinical presentation of rare benign and malignant testis tumors is often similar to that of germ-cell tumors. Likewise, imaging characteristics are also often indistinguishable. However, the management of these rare tumors is often different from the well established treatment algorithms of germ-cell tumors. To that end, it is important for the practicing urologist to be familiar with the current principles of these tumor characteristics and the management.

Paratesticular sarcomas: a case series and literature review

Paratesticular soft tissue tumours are remarkably rare entities, with malignant subtypes accounting for approximately 30%. Due to the paucity of cases, a consensus on the best treatment has not yet been reached, presenting a diagnostic and therapeutic challenge for clinicians. Although rare, three such cases presented to the care of our institution serving a population of approximately 400,000 in the space of 13 months. These were three gentlemen, aged 54, 82 and 86 years old, presenting with left sided testicular swellings. Ultrasound in each case confirmed an extratesticular mass. Only the second gentleman complained of associated pain, however he had experienced scrotal trauma in the preceding weeks. Only one patient had suspicions of metastatic disease, with a 9 mm pulmonary nodule on computed tomography. All patients underwent a radical inguinal orchidectomy with high ligation of the spermatic cord, in keeping with best accepted guidelines. Histology confirmed a well-differentiated liposarcoma, a dedifferentiated liposarcoma and a leiomyosarcoma respectively, all high grade. One gentleman returned to theatre for re-excision of margins. Our case series emphasises the need for full multidisciplinary team specialist sarcoma input, as well as radical resection with judicious margins in order to reduce the risk of local recurrence, in the treatment of these rare tumours.

Current management of paratesticular rhabdomyosarcoma

OBJECTIVES

Paratesticular rhabdomyosarcoma accounts for 7-10% of genitourinary rhabdomyosarcoma tumors and is the 3rd most common after RMS of the prostate and bladder. Though most (60%-80%) patients with paratesticular rhabdomysarcoma present with localized disease, assessment of systemic disease is vital. The treatment of paratesticular rhabdomyosarcoma has evolved over several decades; the current standard of care is multimodal treatment including surgery, chemotherapy, and radiation. We give insight into the evolution of treatment, present the oncologic outcomes of seminal studies, and summarize the current recommendations for the management of these patients.

METHODS

A comprehensive search of the literature on the electronic databases PubMed was conducted for management of paratesticular rhabdomyosarcoma. Case reports were excluded, clinical trials from all the oncologic society were reviewed and relevant articles are included in the review.

RESULTS

The treatment regimen is based on following principles: (1) local control of the primary site with radical orchiectomy and (2) assessment of local control and distant sites. Further treatment is directed according to disease stage, histology, and age of the patient. The goal of treatment is to achieve cure or maximum tumor control while minimizing toxicity.

CONCLUSIONS

With the changing landscape in the management of paratesticular rhabomyosarcoma, significant improvement is evident in the oncologic outcomes. Further advance in genomic testing would lead us to tailor treatment based on individual risk factors and minimize long-term side effects.

High grade myofibroblastic sarcoma of paratesticular soft tissues

Tumors of the paratesticular region most often arise from the soft tissue surrounding the spermatic cord and the epididymis or from the soft tissue (dartos muscle) of the scrotal wall. Paratesticular tumors, despite their rarity, present a high incidence of malignancy (30%), and the therapeutic approach of choice is surgical resection with negative margin. The grade, the histology type, the presence of metastases during the diagnosis, the size of the tumor, the age of the patients, and the surgical margins are all important prognostic factors. We present a case report of a 86-year-old patient with a high grade paratesticular and scrotum sarcoma of soft tissues which was presented as a hard painful mass of the scrotum. The patient was subjected to high ligation of the spermatic cord and received no further treatment and 6 months after the operation no local or systematic recurrence was observed.

Embryonic paratesticular rhabdomyosarcoma: a case report

Introduction

An embryonic paratesticular rhabdomyosarcoma is a very rare mesenchymal tumor. It is an intrascrotal tumor that is localized in paratesticular structures such as the epididymis or spermatic cord. Rhabdomyosarcoma is most often observed in children and adolescents, presenting as a painless scrotal mass.

Case presentation

Our patient was an 18-year-old Moroccan man who presented with a painless left scrotal mass that had evolved over four months. An inguinal orchiectomy was performed. A histological examination of the excised tissue revealed an embryonic rhabdomyosarcoma.

Our patient had three sessions of chemotherapy with vincristine, actinomycin C and cyclophosphamide. Each chemotherapy session was conducted over five days, with a cycle of 21 days. Our patient was assessed two months after the last chemotherapy session and demonstrated good clinical improvement.

Conclusion

Paratesticular rhabdomyosarcoma is a rare aggressive tumor manifesting in children and very young adults. Localized forms have a good prognosis whereas metastatic tumors show very poor results. A well-defined treatment based on surgery and chemotherapy yields good results.

Rhabdomyosarcoma in children

PURPOSE OF REVIEW

Rhabdomyosarcoma is a rare childhood cancer that affects only approximately 300 children per year in the United States. The purpose of this review is to provide the reader a greater understanding of the complex diagnosis, assessment and treatment of rhabdomyosarcoma in children.

RECENT FINDINGS

This review focuses on the new risk classification that is the foundation of all present rhabdomyosarcoma protocols developed by the Children's Oncology Group of the United States and Canada. The new risk classification of low, intermediate and high encompasses the staging and grouping categories that were previously utilized.

SUMMARY

This review also provides a complete list of diagnostic tests and imaging required to identify rhabdomyosarcoma in any body site. Rapid diagnosis and recognition of this rare disorder will facilitate long-term survival. Rhabdomyosarcoma today has an overall survival of 70%, depending on the site, and in orbital and other sites survival is as high as 90%. The treatment approaches that have led to this doubling in survival over the last 25 years are reviewed. For a practitioner, this review can be used as a reference when a child with a suspicious mass is encountered.

Rhabdomyosarcoma of tunica vaginalis masquerading as hydrocele

Paratesticular rhabdomyosarcomas are rare tumors with aggressive growth patterns. Multimodal therapy with surgery, chemotherapy, and radiotherapy provides the patient with an excellent long-term prognosis. These tumors often present in the first two decades after birth. We report on the case of an 18-year-old man with a paratesticular rhabdomyosarcoma.

Clinical Characteristics and Overall Survival in Genitourinary Sarcomas Treated with Curative Intent: A Multicenter Study

OBJECTIVES

Adult soft tissue sarcomas in general, and those arising from the urological organs in particular, are a group of rare tumours with a generally poor prognosis, only a few studies are available. We report our experience with this type of tumours in a multicenter study carried out in a single region of Central Italy (Tuscany).

METHODS

Pre-treatment and follow-up data were obtained from 22 adult patients, all residing in Tuscany, treated consecutively between 1984 and 2002 for primary or locally recurrent genito-urinary sarcomas in 8 urology departments in the area. All cases were classified according to the French Federation of Cancer Center System Grading Scheme for Adult Sarcomas (FFCC) and Broders System. The crude survival probability was estimated by using the Kaplan-Meier method and differences between patient sub-groups were assessed by the log rank test.

RESULTS

The study series included 18 males and 4 females. The mean age at diagnosis was 61+/-21.5 years (range: 15.3-89.1). The most common site was paratesticular (n=9, 40.9%), followed by kidney (n=8, 36.4%), prostate (n=3, 13.6%) and penis and bladder (1 case each, 4.6%). 15 cases (68.2%) were classified as FFCC III, and 16 (72.7%) as Broders IV. The most common histological type was leiomyosarcoma (8 cases, 36.7%), followed by liposarcoma (6, 27.3%), rhabdomyosarcoma (3, 13.6%) and other histological types (5, 22.7%). At the last follow-up (mean: 3.66+/-3.25 years; range 0.15-10.0), 11 of the 22 patients (50%) were still alive. The overall survival rate at 1, 3 and 5 years was 85.9%, 62.0% and 48.8%, respectively. There were no significant differences in survival according to sex, age or histological type. When we compared paratesticular vs. kidney and prostate cancer cases, a significant difference in survival emerged (p=0.02). According to size and grade of the tumour we also found a significant difference in survival (p=0.0006 and p=0.01, respectively).

CONCLUSIONS

In our representative series, 3 tumor parameters (site, size and grade) appeared to represent the most important prognostic factors in adult genitourinary sarcomas.

[Paratesticular rhabdomyosarcoma. A case report]

The rhabdomyosarcomas are rare tumors of mesenchymal tIssue. Whose most frequent localisations are génito-urinary, and occur in the child and young adult. It's an intrascrotal tumour, localised in the tunica vaginalis, epididymis or spermatic cord. The Authors report a case of paratesticular rhabdomyosarcoma in a 15 Year old child, who presented a right painless scrotal mass since two Months. The research of the tumoral markers is negative. Scrotal ultrasound shows a tissular mass in spermatic cord. Abdominal ultrasound and CT show retroperitoneal lymph node mass. Chest X-ray is normal. The intervention consists of a right castration. The histological examination of the spiceman confirms the diagnosis of the paratesticular rhabdomyosarcoma of the spermatic cord. The patient is treated by chemotherapy without improvement. Through this observation, the Authors underline the interest of the imagery and the aspects of the paratesticular tumours in ultrasound and CT.

Rabdomiosarcoma paratesticular

Contribution of one case of paratesticular rhabdomyosarcoma in a 10-years old male patient. Following radical orchiectomy it was classified as Group Ia (Intergroup Rhabdomyosarcoma Study). Treatment was completed with 9 polychemotherapy courses of Ifosfamide, Vincristine and Actinomicine D. The patient was disease-free 6 months after the treatment.

Testicular tumors in children

PURPOSE

The aim of this study was to present an updated picture of surgical management of pediatric testicular tumors based on our 30 years' experience, which consisted of one of the largest noncollected series treated in a single medical center.

METHODS

Records of children who were treated for testicular tumor in our unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical history, clinical characteristics, diagnostic procedures, treatment methods, histopathologic findings, and outcome.

RESULTS

Fifty-one patients with a mean age of 3.8 +/- 0.5 years were treated for testicular tumors. Of these, 35 (69%) had germ cell testis tumor (GCT) and 16 (31%) had non-germ cell testis tumor (NGCT). Endodermal sinus tumor and paratesticular rhabdomyosarcoma were the dominant histologic subtypes in each group, respectively. The most common mode of presentation was painless scrotal mass. At initial presentation, retroperitoneal (n = 5), both retroperitoneal and lung (n = 2), and retroperitoneal and liver (n = 3) metastases were recorded in 10 (19%) patients. Initial operative procedures were radical inguinal orchiectomy (RIO) (n = 29), scrotal orchiectomy (SO; n = 9), bilateral RIO (n = 2), both RIO and unilateral retroperitoneal lymph node (RPLN) excision (n = 6), testis-sparing enucleation of the tumor (n = 5). SOs were performed elsewhere, and these patients underwent high ligation (n = 4) and both high ligation plus RPLN excision (n = 5) in our unit. Histopathologically, spermatic cord invasion and RPLN involvement were present in 10 patients. Scrotal recurrences were encountered in 2 patients who had scrotal orchiectomy initially. Retroperitoneal recurrences were noted in a patient presenting with stage I embryonal carcinoma and in 2 patients presenting with group IV paratesticular rhabdomyosarcoma. The mean follow-up period was 89 +/- 10 months. Four patients with stage IV embryonal carcinoma (n = 2) and group IV paratesticular rhabdomyosarcoma (n = 2) died of progression of the disease. All remaining patients were alive and disease free at their last outpatient appointment. No significant difference was noted with regard to 5-year survival rates between (1) malignant GCT and paratesticular rhabdomyosarcoma patients (91% v 80%) and (2) patients treated by RIO (88%), SO plus high ligation (87%), and RIO plus RPLN excision (80%). Five-year survival rates were 100% for stage I, II, III patients and 33.3% for stage IV and group IV patients presenting with malignant testicular tumors (P <.05).

CONCLUSIONS

Childhood testicular tumors deserve special attention from the therapeutic point of the view. A solid scrotal mass should be considered malignant until proved otherwise. Any suspicion of the testicular tumor warrants an inguinal approach to prevent scrotal violation by the tumor. Current trends emphasize that testis-sparing surgery should be performed for benign lesions such as teratoma, leydig cell tumor, and epidermoid cyst based on frozen biopsy findings. Literature findings and our experience suggest that RIO is the accurate treatment for stage I malignant GCT and group I and IIa paratesticular rhabdomyosarcoma. RPLN excision is not of benefit either as a staging or therapeutic procedure in stage I and group I and IIa diseases of these tumors. RPLN excision should be reserved for (1) malignant GCT patients who have persistent elevation of alpha-fetoprotein after orchiectomy in the presence of normal total body CT scan, and for patients presenting with stage II and III disease with definitive abnormality on CT scans, and (2) group IIb, IIc, and III paratesticular rhabdomyosarcoma patients with radiologic evidence of retroperitoneal involvement on CT scans. High ligation should be done as a complementary procedure after SO to increase the survival rates. J Pediatr Surg 36:1796-1801.

Problems in the imaging of three common paediatric solid tumours

Modern radiologic techniques have led to a more accurate diagnosis and staging in many paediatric malignancies. The optimal imaging of some tumours is not, however, well defined and needs to be constantly re-assessed. Similarly with evolving clinical treatment protocols, recommended imaging strategies should be continually re-evaluated. The significance of some findings on radiologic examinations in paediatric oncology patients is disputed. A number of issues relating to the imaging of Wilms', neuroblastoma and rhabdomyosarcoma in childhood are discussed.

Genitourinary rhabdomyosarcoma. Treatment options

Dramatic improvements have occurred in the treatment and prognosis of the child with rhabdomyosarcoma over the past 2 decades. Increased understanding of tumor behavior has improved survival and focused attention on important quality of life issues. Future therapeutic advances will depend largely on an improved molecular understanding of altered cell behavior and the continued efforts of multi-institutional studies.

Is retroperitoneal lymph node dissection necessary for adult paratesticular rhabdomyosarcoma?

PURPOSE

We assess the benefit of retroperitoneal lymph node dissection for adult paratesticular rhabdomyosarcoma.

MATERIALS AND METHODS

A total of 19 adults with paratesticular rhabdomyosarcoma who underwent retroperitoneal lymph node dissection between 1980 and 1997 comprise our study population. Postoperative chemotherapy was administered in all patients, including cyclophosphamide, doxorubicin and vincristine with or without consolidation with ifosfamide and etoposide in 17, and vincristine, actinomycin D and cyclophosphamide in 2. Radiation therapy also was administered in 2 patients. Patients were classified into pathological and clinical groups according to the Intergroup Rhabdomyosarcoma Studies. Mean followup was 6.4 years (range 0.5 to 17.6).

RESULTS

A total of 17 patients (89%) were disease-free and 2 (1 in pathological group I and 1 in pathological group II) died of disease that recurred outside of the retroperitoneum. Of 16 clinical group I patients 9 were in pathological group II. There were negative nodes in 2 of 3 clinical group II patients. Thus, abdominal computerized tomography correctly staged only 8 of 19 patients (42%).

CONCLUSIONS

Retroperitoneal lymph node dissection accurately stages paratesticular rhabdomyosarcoma and eliminates the need for abdominal radiotherapy in patients in pathological group II. Combined modality therapy with retroperitoneal lymph node dissection and postoperative chemotherapy achieves a high cure rate.

Is retroperitoneal lymph node dissection necessary for adult paratesticular rhabdomyosarcoma?

PURPOSE

We assess the benefit of retroperitoneal lymph node dissection for adult paratesticular rhabdomyosarcoma.

MATERIALS AND METHODS

A total of 19 adults with paratesticular rhabdomyosarcoma who underwent retroperitoneal lymph node dissection between 1980 and 1997 comprise our study population. Postoperative chemotherapy was administered in all patients, including cyclophosphamide, doxorubicin and vincristine with or without consolidation with ifosfamide and etoposide in 17, and vincristine, actinomycin D and cyclophosphamide in 2. Radiation therapy also was administered in 2 patients. Patients were classified into pathological and clinical groups according to the Intergroup Rhabdomyosarcoma Studies. Mean followup was 6.4 years (range 0.5 to 17.6).

RESULTS

A total of 17 patients (89%) were disease-free and 2 (1 in pathological group I and 1 in pathological group II) died of disease that recurred outside of the retroperitoneum. Of 16 clinical group I patients 9 were in pathological group II. There were negative nodes in 2 of 3 clinical group II patients. Thus, abdominal computerized tomography correctly staged only 8 of 19 patients (42%).

CONCLUSIONS

Retroperitoneal lymph node dissection accurately stages paratesticular rhabdomyosarcoma and eliminates the need for abdominal radiotherapy in patients in pathological group II. Combined modality therapy with retroperitoneal lymph node dissection and postoperative chemotherapy achieves a high cure rate.